Long Acting Reversible Contraceptive Referral Letter



Long Acting Reversible Contraceptive (LARC) Referral Letter into Bristol Sexual Health Service (BSHS) from Primary Care

|Patient Details | |Referrer Details | |

|Name | |Referrer Name | |

|Address | |Practice Name | |

| | |Practice Address | |

|Date Of Birth | | | |

|Contact Number | |Contact Number | |

|Contact Permissions | Phone Yes / No |Contact Email | |

| |Text Yes / No | | |

| |Leave Message Yes / No | | |

Please note that due to funding issues we are unable to insert IUS for gynaecological reasons alone eg postmenopausal endometrial protection or heavy menstrual bleeding in a woman who has been sterilised - these patients require gynaecology referral.

Dear colleague, Referral Date

Following a discussion on contraception choices with this patient we are pleased that she has chosen to have a long acting reversible contraceptive fitted:

IUD IUS Implant

Unfortunately we are unable to initiate the method on this occasion due to the following reason:

A) We are not signed up to a Local Authority contract with Public Health to deliver the above LARC method

B) We are contracted to deliver the above LARC method, but there are no professionals currently available trained in this method and my local authority commissioner has been informed1

C) We are contracted to deliver the above LARC method, but patient prefers to be seen at BSHS due to a previous difficult fit

D) Failed removal2 or insertion (please provide further details below)

Details

2 all lost thread referrals for removal must have an ultrasound report included from the last 6 months confirming that the IUS/IUD is in situ. For complex implant removals please state whether the implant was palpable.

E) Medical concerns (please provide any other relevant details below)

Details

Medical History & Current Medication

Please provide details below or attach a printout of recent attendances and medications/allergies.

Is current method lifespan expired? Yes / No

If yes give date

If due to expire give date

We have provided her with the following bridging method of contraception until she has her LARC method fitted:

Condoms

Combined oral contraceptive pill

Progestogen only pill

Please inform the patient that due to increasing demand, there is often a wait of several weeks for complex insertions and/or removals with BSHS

Yours sincerely

1Contact details for local authority commissioners are:

Bristol City Council

Annette Billing, Public Health Principal (Sexual Health)

Annette.Billing@.uk 0117 922 3694

North Somerset Council

Fiona Miles Health Improvement Specialist

Fiona.Miles@n-.uk 01275885576

South Gloucestershire Council

Lottie Lawson, Health & Well Being Partnership Officer (Sexual Health)

Lottie.Lawson@.uk 01454 866195

-----------------------

Please complete this form as fully as possible. Patients will be contacted by the BSHS Team to arrange an appointment once the referral has been received and triaged.

Please post or fax the form to : Fay Webb (LARC referral administrator)

BSHS, Central Health Clinic,

Tower Hill BS2 0JD

Fax: 0117-925 3400

Any queries telephone Fay Webb: 01173426951

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download